Provider Demographics
NPI:1578646311
Name:SUREEPISARN, LAURA ANN (MHP)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:ANN
Last Name:SUREEPISARN
Suffix:
Gender:F
Credentials:MHP
Other - Prefix:MISS
Other - First Name:LAURA
Other - Middle Name:ANN
Other - Last Name:DOUGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:4604 101ST PL NE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-2361
Mailing Address - Country:US
Mailing Address - Phone:360-659-5943
Mailing Address - Fax:
Practice Address - Street 1:4604 101ST PL NE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-2361
Practice Address - Country:US
Practice Address - Phone:360-659-5943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00029837101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health